The examination of a patient with acute low back pain (LBP) includes the clarification of complaints and history data, brief physical and neurological examinations, and an assessment of danger symptoms. The diagnosis of acute nonspecific (musculoskeletal) LBP is based on the exclusion of a specific cause of pain (a potentially dangerous disease), discogenic radiculopathy, and lumbar spinal stenosis. If there is typical musculoskeletal pain and no danger symptoms, radiography, X-ray computed tomography, and magnetic resonance imaging are not recommended in the first 4 weeks of disease. Whether it is expedient to perform these techniques is considered when LBP persists over this time period. A patient with acute nonspecific (musculoskeletal) LBP should be informed about the favorable outcome of the disease and the need to maintain physical and social activities, to avoid bed rest, and, if possible, to continue professional activities. The lowest effective dose of nonsteroidal anti-inflammatory drugs for short-term duration, as well as muscle relaxants (the medium level of evidence) can be used to relieve pain. It is recommended that one should use an educational program (to prevent over-exercising and prolonged standing or sitting in static and awkward positions; to lift weights properly; etc.) to prevent recurrent LBP, as well as therapeutic exercises during a non-exacerbation period.

ORIGINAL INVESTIGATIONS

The diagnosis of transient ischemic attack (TIA) is fraught with problems; particularly this concerns the differentiation of TIA with its mimicking conditions. Explicit diagnostic criteria can improve the accuracy of TIA recognition. The authors of this paper propose new TIA diagnostic criteria

Objective: to elaborate TIA diagnostic criteria and to determine their sensitivity in a group of patients with TIA, as well as their specificity in those who suffered from migraine with aura from Russia and Denmark.

Patients and methods. TIA diagnostic criteria were developed using the International Classification of Headache Disorders (ICHD) and the data available in the literature on migraine with aura and on the clinical characteristics and diagnosis of TIA. The sensitivity of the criteria was tested in a prospective study of 120 patients who developed TIA before the elaboration of these criteria. The patients were questioned in the acute period of the disease through detailed semi-structured interviews. Eligible patients had focal brain or retinal ischemia with resolution of symptoms within 24 hours without acute brain tissue damage, as evidenced by diffusion-weighted magnetic resonance imaging (n=112) or computed tomography (n=8). These criteria were also tested for specificity in Danish (n=1390) and Russian (n=152) patients suffering from migraine with aura, the diagnosis of which was established according to ICHD-3 beta.

Results and discussion. The sensitivity of the proposed criteria in TIA patients was 99%. The specificity in the Danish and Russian patients with migraine with aura was 95% and 96%, respectively.

Conclusion. The new TIA diagnostic criteria are characterized by high sensitivity and specificity. These will be able to improve the diagnosis of TIA. It is recommended that the testing of these criteria in patients with TIA should be continued in future investigations.

Patients and methods. The investigation enrolled 82 people aged 40–59 years (41 patients with EH and 41 healthy individuals (a control group)). Twenty-four blood pressure monitoring and brain MRI were performed in different modes (T1 MPRAGE, T2 TSE, T2 FLAIR, and DTI).

Results. White matter hyperintensities (WMHs) were found in 7.3% of the healthy individuals and in 53.7% of the hypertensive patients (p=0.0002). The latter had significantly lower fractional anisotropy (FA) values in the white matter of the left inferior frontal gyrus than the healthy individuals (0.39±0.06 and 0.45±0.09, respectively; p<0.001). FA was lower in the hypertensive patients than in the healthy individuals not only in the presence of WMHs (the left inferior frontal gyrus white matter was 0.397±0.071 and 0.45±0.09, respectively; p=0.009; the genu of the corpus callosum was 0.79±0.04 and 0.81±0.05, respectively; p=0.045), but also in the absence of WMHs (the left inferior frontal gyrus white matter was 0.378±0.073 and 0.45±0.09, respectively; p=0.0007). Discussion. The treatment-naХve patients with uncomplicated grade 1–2 EH with short-term (2,3 year) duration were found to have significantly lower FA values in the left inferior frontal gyrus white matter than the healthy normotensive subjects of the same age. Thus, the microstructural integrity of white matter is impaired in middle-aged hypertensive patients even at the earliest disease stages.

Conclusion. Middle-aged treatment-naive patients with uncomplicated grade 1–2 EH have lower FA in the left inferior frontal gyrus white matter even in the absence of WMHs.

Parkinson's disease (PD) is now increasingly considered as a multi-system disorder associated with multi-neurotransmitter dysfunction, so it is important to search for genetic risk factors that determine different clinical types of this disease.

Objective: to investigate the associations of PD with the polymorphic variants of glutamatergic system genes, such as GRIN2A encoding the N-methyl-D-aspartate (NMDA) receptor; SLC1A2 encoding the glial glutamate transporter; and GRIK4 encoding the ionotropic glutamate kainate receptor.

Patients and methods. Examinations were made in 222 patients diagnosed with Parkinson's disease and 318 healthy individuals, who were an ethnic Russian population from the Siberian Region. Genotyping using one single-nucleotide polymorphism was performed in three glutamatergic system genes: the polymorphisms were rs2650427 in the GRIN2A gene, rs4354668 in the SLC1A2 gene, and rs1954787 in the GRIK4 gene. The results were statistically processed using the SPSS Statistics 23.0.

Results and discussion. In the group of patients with tremor-dominant PD, the GRIK4 polymorphism rs1954787 showed a considerable increase in frequency of the T allele (66.7%) and a reduction in that of the C allele (33.3%) as compared to their distribution in the control group (42.1 and 57.9%, respectively; χ2 =7.70; p=0.006). The odds ratio (OR) was calculated for all of the genotypes and alleles of the investigated polymorphisms; the ratio showed that the C allele of the GRIK4 polymorphism rs1954787 had a protective effect (OR, 0.36; 95% CI, 0.17–0.76), whereas the T allele (OR, 2.75; 95% CI, 1.32–5.75) and the homozygous TT genotype (OR, 3.40; 95% CI, 1.21–9.53) were found to predispose to the development of tremor-dominant PD.

Conclusion. The found significant association of the GRIK4 polymorphism rs1954787 with the tremor-dominant PD may suggest that abnormalities in the glutamatergic system play a role in the pathophysiological processes of the disease.

Results and discussion. These treatments showed high efficiency and safety. Three months after a treatment cycle, there were reductions in the intensity of pain (by an average of 47%; p<0.0001) and in the degree of disability and improvements in the physical and psychological parameters of quality of life. There were no substantial differences in the health status of patients in the two groups treated with blockades with anesthetics and GCs or SIJ RFD.

Conclusion. It has been shown that the incorporation of blockades with anesthetics and GCs or SIJ RFD into the treatment of patients with chronic low back pain can improve the results of therapy.

Objective: to carry out a systems analysis of the molecular mechanisms of action of the chondroprotector Sustaguard® Arthro based on the microcrystalline pharmaceutical substance glucosamine sulfate (GS) manufactured by Bioiberica S.A.U. (Spain).

Material and methods. The systems analysis of the molecular mechanisms was based on literature data and proteomic databases through machine learning systems.

Results and discussion. GS interacts with the receptors CD44, TLR4, and ICAM1 on the surface of chondrocytes, inhibits the proinflammatory transcription factor NF-κB and the cytokine signaling pathway JAK/STAT, and regulates the synthesis of IgA, the migration of leukocytes, and the activity of hematopoietin and interferon receptors.

Conclusion. The findings indicate that there are molecular mechanisms of synergism between glucosamine and nonsteroidal anti-inflammatory drugs in the therapy of cartilage tissue pathology.

Objective: to study of the individual aspects of the relationship and interaction of menstrual and generative function and depressive disorders in women.

Patients and methods. 120 women aged 18–65 years with recurrent depressive disorder (RDD) who had experienced at least two depressive episodes (a study group) and 120 mentally healthy women of the same age (a control group) were clinically examined using a specially designed map with subsequent statistical processing of the findings.

Results and discussion. In 71.7% of women, depression manifests itself during hormonal rearrangement periods (puberty, postpartum, and menopause). 65.0% of women with RDD have premenstrual syndrome (PMS), the pattern of which shows depressive symptoms. Depression affects menstrual function: the later onset and irregularity of menstruation, the earlier restoration of menstrual function after childbirth, and the earlier onset of premenopause, which has an adverse impact on generative function (a reduction in the number of pregnancies, births, and babies). Depression, the onset of which is observed during puberty, exerts the most malignant effect on menstrual and generative function. Overall, depressive patients are less socially and family-friendly than healthy women. Menstrual and generative function and adaptation minimally suffer in women with postmenopausal depression.

Conclusion. The onset of depressive disorders is associated with the hormonal rearrangement periods. The presence of depressive symptoms in the pattern of PMS is a prognostic sign of future depression or indicates partial remission. At the same time, menstrual function is impaired in women suffering from RDD, which along with psychic manifestations of depression (a decrease in sexual drive and contacts, as well as anesthesia of feelings, etc.) leads to infertility.

Objective: to investigate and analyze the specific features of mental development in children with opsoclonus-myoclonus syndrome (OMS) in relation to the number of exacerbations.

Patients and methods. A total of 19 infants (8 boys and 11 girls) aged 1 year 7 months to 10 years 7 months with OMS were examined. The investigation included an analysis of medical records, a follow-up of the children with evaluation of their behavior, emotional responses, and mental functions, and an interview with their parents. Pathopsychological and neuropsychological examinations were used separately for children under 5 years and for those over 5 years, respectively.

Results and discussion. It was established that a larger number of OMS exacerbations increased the severity of mental developmental disorders in children if they had >5 deteriorations; there was a severe developmental retardation. The children with OMS were found to have the features of an emotional state and motor behavior and a stable set of the most vulnerable mental processes and functions in the presence of the disease: the neurodynamic features of mental processes; impairments in the motor component of mental functions, including speech; visual and spatial deficits. Positive trends in mental development (as general cognitive interest, readiness for communication with adults) are suggestive of the potential compensation resources that should be used for the psychocorrection and rehabilitation of children with OMS.

Conclusion. Mental retardation is seen in children with OMS, the severity of which increases with the number of disease relapses. There is a need for further studies of children with OMS.

The paper presents the results of examination and treatment in patients in the early recovery period of ischemic stroke. It considers the concurrent use of drug and speech therapies to improve the rehabilitation of patients with post-stroke speech and swallowing disorders.

Objective: to identify the role of speech-language therapy and neuropsychology sessions in the treatment of speech and swallowing disorders in the early recovery period of ischemic hemispheric stroke.

Patients and methods. A total of 45 patients (32 (71%) men and 13 (29%) women) with a 2–3-month history of ischemic hemispheric stroke were examined. The follow-up period was 2 months. The patients were divided in two groups. Group 1 (a study group) included 30 patients who received combination therapy (drug treatment; sessions with a speech-language pathologist; and compensatory treatments for restoring swallowing function). All the patients had moderate dysphagia accompanied by speech disorders. Moderate sensorimotor aphasia was observed in 15 patients; moderate dysarthria was also seen in 15 patients. Vinpocetine (Cavinton®) and its dispersible tablets (Cavinton® Comfort) were chosen as an agent for vasoactive therapy. Group 2 (a comparison group) consisted of 15 patients with dysphagia who had only standard therapy and speech therapy sessions. There was sensorimotor aphasia in 2 (4%) patients and dysarthria in 13 (29%). A complex psychological and logopedic examination was carried out using the Mann Assessment of Swallowing Ability (MASA), dysarthria assessment, and the scale designed by L.I. Vasserman for estimating the degree of speech disorders in patients with local brain injuries.

Results and discussion. Posttreatment swallowing function improved in all the 45 patients; however, more pronounced positive changes were recorded in the patients of Group 1 (p< 0.05). Survey data, possible diet modification, better patient communications, improved quality of life in the patients, and the opinions of their relatives and medical staff served as criteria for the effectiveness of the model used to recover swallowing function. A subjective improvement showed itself as an increased ability to initialize the pharyngeal phase of swallowing in 25 (56%) patients and none mild delays (up to 5 sec) in the movement of a food bolus in the oral cavity in 10 (22%) patients and in the intake of the food of different consistency in 10 (22%). After a treatment cycle in Group 1, the number of patients with mild dysphagia increased up to 30%; moderate swallowing disorders were present in 63% of patients, which required that medical and speech correction should be continued. A significant improvement in swallowing function was noted in 10% of Group 1 patients with medium-sized cortical and cortical-subcortical lesions; a moderate improvement was seen in 67% with medium and small cerebral foci at the same location. At the same time, in Group 2 there were insignificant positive changes only in 20% of patients, most of whom had dysarthria.

Conclusion. The high incidence of post-stroke makes it reasonable to use speech therapy methods in a set of multidisciplinary specialized types of care. This care should be personalized; prescribing easy-to-swallow dispersible drugs plays an important role in this case. This will improve quality of life in the patient and protect him from unwanted complications.

Adherence to long-term medication is one of the most important components of effective therapy. Many factors have a substantial influence on medication adherence; a special role among them is played by cognitive impairment (CI).

Objective: to identify whether poststroke patients have pre-stroke cognitive deficit and to assess its impact on adherence to long-term medication.

Patients and methods. A total of 103 patients with acute ischemic stroke in the carotid system were examined. The mean age of the patients was 64.18±10.24 years. The Montreal Cognitive Assessment (MoCA) was applied to assess cognitive functions; the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) was used to determine the presence of pre-stroke cognitive decline. Data concerning vascular risk factors were collected for all the patients. Medication adherence was retrospectively evaluated using the Morisky–Green scale.

Results and discussion. Our study showed that only 44.7% of patients were adherent to long-term medication before the stroke. Patients who were engaged in manual labor during their lives were significantly more poorly compliant. Chronic heart failure was also responsible for a reduction in medication adherence. Pre-stroke cognitive deficit was present in 53.4% of the examinees. Unlike patients with normal cognitive function, the majority of patients with pre-stroke CI were non-adherent to medication (28.1 and 71.9%, respectively). At the same time, the adherence to long-term medication depended on the severity of cognitive deficit.

Conclusion. The results of the investigation suggest that CI has a considerable impact on adherence to long-term therapy. To improve primary stroke prevention, cognitive functions should be evaluated in all patients with vascular diseases who receive long-term drug treatment. When CI is identified, there is a need for targeted drug treatment and its proper monitoring.

Objective: to evaluate the efficiency of incorporating of mexidol into combination drug therapy for elderly patients with acute ischemic and hemorrhagic stroke (IS and HS).

Patients and methods. Sixty patients aged 60 to 74 years with new-onset hemispheric stroke were examined. 34 patients of them were diagnosed with IS; 26 patients had intracerebral bleeding (ICB). A study group consisted of 31 patients who had taken mexidol in addition to therapy in accordance with the standards adopted in the Russian Federation. A comparison group included 29 patients who used only the standard therapy. Indicators were assessed using the National Institutes of Health Stroke Scale (NIHSS), the Riverbed mobility index, the modified Rankin scale, and the Barthel index before and during intravenous dropwise infusion of mexidol 500 mg for 10 days. The percentage absorption of lipidphospholipid complexes was also examined in the infrared spectrum of blood serum. A control group compromised 20 healthy individuals.

Results and discussion. The time course of changes in the serum lipid-phospholipid complexes was found to correlate with the type of stroke. The incorporation of mexidol into combination drug therapy for elderly patients with the acute period of IS and ICB contributed to the regression of focal neurological deficit and to the improvement of daily activity and functional independence. Mexidol also exerted a positive effect on the level of neuronal membrane phospholipids.

Conclusion. Mexidol was noted to have a positive effect on serum phospholipid levels. It is concluded that the incorporation of the drug into the combination therapy is effective in patients with acute IS and HS, in elderly people in particular.

CLINICAL OBSERVATIONS

CLIPPERS syndrome (Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids) is a recently described rare disease affecting the central nervous system. It is characterized by subacute development of symptoms of lesions predominantly in the brain stem and cerebellum, by specific magnetic resonance imaging (MRI) changes, perivascular lymphocytic infiltration in the brain substance and a good response to glucocorticoid (GC) therapy. The paper describes CLIPPERS syndrome in a patient who has been followed up in a clinic for 10 years. During this period, different variants of clinical diagnosis have been considered. The final diagnosis was made only when comparing the clinical course and manifestations of the disease, MRI data, as well as the reaction to GC therapy and its discontinuation. Literature data and diagnostic criteria of this disease are presented.

Charles Bonnet syndrome (CBS) includes the visual hallucinations in patients with decreased/lost vision in both eyes or hemianopsia, which are unassociated with cognitive dysfunction or confusion. The paper describes a clinical case of a 77-year-old woman who had daily complex mobile visual hallucinations occurring mainly in the early dawning with open eyes and in clear consciousness. The patient was referred to the vascular center with lacunar stroke detected by magnetic resonance imaging, which was asymptomatic and could not cause hallucinations. The latter appeared for the first time a year before stroke in the presence of a dramatic bilateral visual decrease caused by proliferative diabetic retinopathy. The hallucinations were regarded as a manifestation of the CBS. Adequate therapy led to their disappearance. The paper provides a review of current publications on the prevalence, causes, clinical presentations, and treatment of CBS.

The socially significant problems in patients with prior stroke include post-stroke cognitive impairment (PCI), the prevalence of which is high (from 24 to 70%). The causes of disability in these patients are that the role of cognitive impairment is often underestimated and attention is paid only to motor defects. The pathogenesis of PCI may include not only vascular, but also neurodegenerative (due to Alzheimer's disease) mechanisms of brain damage. The diagnosis of early PCI is of great practical importance, as it is most effective to treat mild PCI. The paper considers current approaches to preventing and treating PCI. The authors give their own experience in treating a patient with moderate PCI.

REVIEWS

The paper discusses the effects of drugs from different pharmacological groups on cognitive functions. It details the impact of drugs used to treat nervous system, cardiovascular, gastrointestinal, respiratory, and endocrine diseases on cognitive functions. It is emphasized that many drugs exert both negative and (less frequently) positive effect on cognitive functions, but it is especially pronounced in drugs used to treat nervous system diseases. There is evidence suggesting that different representatives of a number of pharmacological groups have no class effect on cognitive functions.

Dementia develops as a result of continuous long-term progression of less severe cognitive impairment (CI). Social and psychological methods (neurocognitive stimulation and neurocognitive training) are the mainstay of treatment for dementia. At the moment, there are no drugs both to cure dementia and to stop the degeneration of nerve tissue. Modern pharmacotherapy for dementia aims to maintain cognitive functions in the patient for as long as possible and to slow down disability, thus ensuring higher living standards. CI therapy most often consists of compensation for cognitive defect. Among the whole variety of pharmacological agents, the effective drugs to treat dementia are only two groups, such as acetylcholinesterase inhibitors and N-methyl-D-aspartate (NMDA) glutamate receptor antagonists. Atypical neuroleptics are employed for the treatment of psychotic disorders; antidepressants from a group of selective serotonin reuptake inhibitors are for depression. Cognitive behavioral therapy and cognitive stimulation deserve special attention. A high educational level and physical, social, and intellectual and activities can prevent dementia.

The paper highlights the main ways to increase the efficiency of mental health care according to the data available in foreign and Russian literature. It sets forth the main directions for development of mental health care and the possibilities of their implementation. The basic documents of the World Health Organization, which define the most important vectors of the development of European psychiatry, are considered.

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